Glaucoma Past, Present and Future

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Kimberly Cole
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1 Glaucoma Past, Present and Future Paul A. Weber, M.D. Professor Emeritus Department of Ophthalmology and Visual Science- Havener Eye Institute The Ohio State University

2 Before we talk about glaucoma, I need to talk a little bit about The Most Important Square Inch of the Body

3 All diagnosed with the ophthalmoscope Diabetes Hypertension Carotid Artery Disease Lupus MS Brain Tumor Sickle Cell Anemia Leukemia AIDS Metastatic Disease PMR Sarcoidosis SBE IV Drug Abuse Syphilis

4 Fear of going blind People are twice as afraid of going blind as they are of dying

5 Sensory Overload 80% of our brain is related to vision 60% of sensory input to the cerebral cortex is deprived by vision loss

6 Visual Imagery It was raining harder than a cow pissing sideways on a rock

7 Glaucoma Past Glaucoma has been known in medicine since antiquity. Hippocrates described glaykoseis as blindness which occurs in the elderly. The invention of the ophthalmoscope in 1850 by Helmholtz made it possible to diagnose glaucoma changes in the eye. The first effective surgical treatment was carried out by von Graefe in In 1877, Adolf Weber discovered that a drop called pilocarpine could lower the eye pressure

8 Glaucoma Present

9 Glaucoma Third leading cause of blindness worldwide Second leading cause of blindness among whites in U.S Leading cause of blindness among African Americans in U.S.

10 Glaucoma Affects 2.2 million in US Prevalence Age 40 and over - 1.9% Age 75 and over - 7% Blacks 3-4x greater than whites Blacks age 80 and over - 10%

11 Glaucoma Types Some 55 different types Open Angle Congenital Glaucoma Angle closure

12 Glaucoma - Definition Glaucoma is a disease of the optic nerve. Most, but not all, patients have a high eye pressure.

13 Anterior Chamber Angle Conjunctiva Iris Cornea Canal of Schlemm Aqueous Vein Trabecular Meshwork Collector Channel

14 Open Angle Glaucoma Symptoms None!

15 Why are patients unaware of their loss of vision from glaucoma until very late in the disease?

16 The visual loss in glaucoma is usually gradual (over several years), and affects the side or peripheral vision first.

17 Glaucoma Vision Loss

18 Glaucoma Vision Loss

19 Open Angle Glaucoma Prognosis Visual loss is irreversible When diagnosed early, excellent prognosis for normal vision Most cases of blindness are diagnosed at an advanced stage

20 Glaucoma diagnosis - The optic nerve

21 Glaucoma - Diagnosis We need to determine if the optic nerve is damaged by glaucoma Visual field testing (peripheral vision) Optical coherence tomography (OCT) like an ultrasound but with light rays

24 Comparison of OCT Images OCT 1 (Time Domain) 1996 Stratus OCT (Time Domain) 2002 RTVue (Fourier Domain) 2006

25 Retinal Layers with RTVue & Histology Temporal Fovea Parafovea Blood vessel Nasal ILM NFL GCL IPL INL OPL ONL PR IS/OS RPE Choriocapillaris and choroid

26 OCT

27 OCT Ganglion Cell Map

28 Glaucoma Progression

29 Glaucoma Treatment If you lower the eye pressure, whether it is high, normal or low, you can stop or slow down glaucoma damage

30 Eye drops Pills Glaucoma Treatment Lowering Eye Pressure Intravenous medications Laser surgery Cutting surgery

31 Glaucoma Treatment Eye Drops

32 Glaucoma Treatment Eye Drops We cannot predict which eye drops will work or be tolerated in any patient It is trial and error

33 Vyzulta Rhopressa Eye Drops Just approved this year!

34 Laser Surgery

35 Laser Trabeculoplasty

36 Glaucoma Treatment - Cutting Surgery Trabeculectomy

37 Glaucoma Treatment Cutting Surgery Glaucoma Tube-Shunt

38 Seton

39 Trabeculectomy Canal of Schlemm

41 Glaucoma Surgery - Present Minimally Invasive Glaucoma Surgeries (MIGS) - istent

42 Glaucoma Surgery - Present MIGS -istent

43 Glaucoma Surgery - Future MIGS

44 Glaucoma Surgery Future MIGS

45 Glaucoma Future Education Ophthalmoscope Simulator

46 Glaucoma Future New medication delivery

47 Glaucoma Future New medications to lower eye pressure Neuro-protective agents Optic nerve regeneration Gene therapy Gene augmentation Gene silencing Gene editing Genes as drugs

48 Glaucoma Future Why do some eyes with high eye pressure don t develop glaucoma? Why do some eyes with normal eye pressure develop glaucoma?

49 Two theories we re doing research on: Biomechanical theory Low intracranial pressure Cynthia Roberts, Ph.D. Jun Liu, Ph.D Gloria Fleming, M.D. Robert Small, M.D.

50 Translaminar Pressure Gradient

Pressure Gradient Cynthia Roberts, Ph.D.

51 The Influence of Tonometric Technology and Body Position on the Calculation of the Pulsatile Translaminar Pressure Gradient Cynthia Roberts, Ph.D. Gloria Fleming, M.D. Robert Small, M.D. Paul Weber, M.D. Biomedical Engineering

Standard Procedure SLOW while waiting for fluid to rise http://webmedia.

com/product/lumbar-puncture-and-lumbar- Epidural-Replacement-Tissue.

52 Standard Procedure SLOW while waiting for fluid to rise Epidural-Replacement-Tissue.aspx?cid=556 It is possible retrospective study used values that were UNDER-ESTIMATED

53 Electronic Measurement of CSF Pressure during Lumbar Puncture Plugged into Standard Monitor To Spinal Needle Transducer To Pressurized Fluid Reservoir

54 Lateral Decubitus (LD) Position

55 Ultrasound-Guidance of Spinal Needle Placement L4 L5 S1 SonoSite Model M-Turbo

Doctoral student, Ryan Somogye, designed and built an interface to

56 Reichert Model 30 Pneumatonometer Produces a strip-chart, rather than a digital output. Doctoral student, Ryan Somogye, designed and built an interface to allow direct connection with patient monitor - used for a subset of the later subjects. This allowed direct subtraction of signals.

57 Is there any practical way to evaluate this issue?

59 OCT Reflectivity Changes in OCT reflectivity of the lamina cribrosa result from changes in the stress distribution of the lamina

60 Sitting

61 Supine

62 OCT Reflectivity

64 Thank You!

Glaucoma. Glaucoma. Optic Disc Cupping

Glaucoma. Glaucoma. Optic Disc Cupping Glaucoma What is Glaucoma? Bruce James A group of diseases in which damage to the optic nerve occurs as a result of intraocualar pressure being above the physiological norm for that eye Stoke Mandeville